2008: Measles in Dr. Bob Sears' Waiting Room

I thought this to be a timely topic given the current measles outbreak that is occurring in a very undervaccinated population in Minnesota.  Thus far, there are 14 cases in Hennepin County, 13 of which are epidemiologically-linked in the Somali population there.  This situation highlights the infectiousness of measles and how easily it can be spread to immunologically-naive people, even with overall high vaccination rates.  Uptake of MMR is estimated to be greater than 95% in 70% of U.S. schools, however, private schools are not surveyed and 12 states were below 95% with some as low as 81%.  There is also geographical clustering of "like-minded" people in communities that leave large numbers of susceptible children at risk for measles.  Additionally, lists of "vaccine-friendly" doctors, like this one provided by Dr. Bob can be geographically-linked to large numbers of school exemptions for vaccines.

This is what can, has and will happen again with the current recommendations that these "vaccine-friendly" doctors make:  In 2008, an intentionally unvaccinated 7 year old child came back to the states from a visit to Switzerland with his parents.

In January 2008, measles was identified in an unvaccinated boy from San Diego, California, who had recently traveled to Europe with his family. After his case was confirmed, an outbreak investigation and response were initiated by local and state health departments in coordination with CDC, using standard measles surveillance case definitions and classifications.* This report summarizes the preliminary results of that investigation, which has identified 11 additional cases of measles in unvaccinated children in San Diego that are linked epidemiologically to the index case and include two generations of secondary transmission. Recommendations for preventing further measles transmission from importations in this and other U.S. settings include reminding health-care providers to 1) consider a diagnosis of measles in ill persons who have traveled overseas, 2) use appropriate infection-control practices to prevent transmission in health-care settings, and 3) maintain high coverage with measles, mumps, and rubella (MMR) vaccine among children.

The index patient was an unvaccinated boy aged 7 years who had visited Switzerland with his family, returning to the United States on January 13, 2008. He had fever and sore throat on January 21, followed by cough, coryza, and conjunctivitis. On January 24, he attended school. On January 25, the date of his rash onset, he visited the offices of his family physician and his pediatrician. A diagnosis of scarlet fever was ruled out on the basis of a negative rapid test for streptococcus. When the boy's condition became worse on January 26, he visited a children's hospital inpatient laboratory, where blood specimens were collected for measles antibody testing; later that day, he was taken to the same hospital's emergency department because of high fever 104°F (40°C) and generalized rash. No isolation precautions were instituted at the doctors' offices or hospital facilities.

The boy's measles immunoglobulin M (IgM) positive laboratory test result was reported to the county health department on February 1, 2008. During January 31--February 19, a total of 11 additional measles cases in unvaccinated infants and children aged 10 months--9 years were identified. These 11 cases included both of the index patient's siblings (rash onset: February 3), five children in his school (rash onset: January 31--February 17), and four additional children (rash onset: February 6--10) who had been in the pediatrician's office on January 25 at the same time as the index patient. Among these latter four patients, three were infants aged less than 12 months. One of the three infants was hospitalized for 2 days for dehydration; another infant traveled by airplane to Hawaii on February 9 while infectious.

Just the Vax reported earlier that the index case (the intentionally unvaccinated boy travelling from Switzerland) was Dr. Bob Sears' patient.   But there is now more.  That boy, the index case, infected four other children in the waiting room of his paediatrician's office.  The office of Dr. Bob Sears.  I suspected this was the case and it was confirmed when Dr. Bob appeared on the Dr. Oz Show, "What Causes Autism" with Dr. Ari Brown who stated:

"...And as an example, there was a 2008 measles outbreak in San Diego where an unvaccinated child developed measles, was in the doctor's waiting room where other unvaccinated children then got measles.  In fact one of those children was too young to be vaccinated and contracted measles and ended up in the hospital.  And I think those were actually Dr. Bob's patients."

Dr. Bob did not deny this.

In reality however, there were three infants and one toddler who contracted measles in his waiting room.  Here is the story of the one who ended up in the hospital:

If you hear "106 degrees" you probably think "heat wave," not a baby’s temperature. But for Megan Campbell’s 10-month-old son, a life-threatening bout of measles caused fevers spiking to 106 degrees and sent him to the hospital.

"After picking our son up at child care because he had a fever," says Megan, "we went straight to our pediatrician who said our baby had a virus. Two days later, his fever hit 104 degrees and a rash appeared on his head."

The rash quickly crept down to his arms and chest. Megan and husband Chris turned to the Internet. Finding pictures of measles that looked like their son’s rash, they rushed him to the local children’s hospital.

"No one there had seen or tested for measles for about 17 years," says Megan. "And no one expected it in the year 2008 in the United States. The next day, an infectious disease specialist confirmed measles.

"We spent 3 days in the hospital fearing we might lose our baby boy. He couldn’t drink or eat, so he was on an IV, and for a while he seemed to be wasting away. When he began to be able to drink again we got to take him home. But the doctors told us to expect the disease to continue to run its course, including high fever—which did spike as high as 106 degrees. We spent a week waking at all hours to stay on schedule with fever reducing medications and soothing him with damp wash cloths. Also, as instructed, we watched closely for signs of lethargy or non-responsiveness. If we’d seen that, we’d have gone back to the hospital immediately."

Thankfully, the baby recovered fully.

Megan now knows that her son was exposed to measles during his 10-month check-up, when another mother brought her ill son into the pediatrician’s waiting room. An investigation found that the boy and his siblings had gotten measles overseas and brought it back to the United States. They had not been vaccinated.

"People who choose not to vaccinate their children actually make a choice for other children and put them at risk," Megan explains. "At 10 months, my son was too young to get measles, mumps, rubella (MMR) vaccine. But when he was 12 months old, we got him the vaccine—even though he wasn’t susceptible to measles anymore. This way, he won’t suffer from mumps or rubella, or spread them to anyone else."

This story is one of many recounted in the fact sheets series, Diseases & the Vaccines that Prevent Them.
For other true stories, see Vaccines: Unprotected Stories.

I wonder if Dr. Bob and his merry band of "disease-friendly doctors" provide information to their vaccine-refusal clients shown in the links above, let alone tell parents of his own practice's patient who was infected while waiting for his well check-up.  Unfortunately, this isn't all to that story.  It appears as though Dr. Bob or one of his practice partners doesn't even know what measles looks like:

First Generation (1 Case Spread to 8)

On January 13, 2008, the 7-year-old male index patient returned from Switzerland, asymptomatic but incubating measles. He transmitted infection to his 9-year-old unvaccinated sister and 3-year-old unvaccinated brother. On January 24, 2008, after 2 days of fever and conjunctivitis, the index patient attended charter school A. Forty-one of the 377 students (11%) at charter school A were unvaccinated for measles because of personal beliefs, and 2 children became infected. The next day, the index patient developed a rash and was taken to an internist who diagnosed an upper-respiratory infection and prescribed amoxicillin. No airborne-infection isolation precautions were taken; adults in the waiting room were exposed, but none of them became infected. Later the same day, the index patient was taken to pediatric clinic A, where scarlet fever was diagnosed; again, amoxicillin was prescribed. No respiratory precautions were taken, 6 children were exposed, 5 were unvaccinated, and 4 were infected (3 infants too young for vaccination and a 2-year-old whose parents had intentionally delayed measles vaccination). The next day, after telephone consultation with a pediatrician, the child was taken for measles serology testing. No respiratory precautions were taken in the clinical laboratory, and no records were kept to permit identification of potentially exposed persons. With worsening fever, the index patient was taken to a children’s hospital emergency department, where measles was clinically diagnosed. The patient was triaged, placed in a negative-airflow waiting room, and then examined in a room with curtain-separated beds and no negative airflow, all without wearing a mask. Thirteen children were potentially exposed, and 5 were unvaccinated infants; none of them were infected.

Emphasis added.  A disease-friendly physician, such as Dr. Bob should know what measles looks like, and certainly be able to distinguish it from Scarlet Fever; there are tests for both.  Even after this incident, Dr. Bob still recommends delaying MMR until 4 years old and recommends only a single dose.  The parents of the index case are certainly not without fault as they intentionally left their child unvaccinated for measles, at the very least, travelled to an area with a relatively high prevalence of measles, in fact during that time, a record number of measles cases since mandatory reporting began in 1999 and then don't even know what measles looks like themselves, eventually exposing hundreds of people.  The eventual cost of Dr. Bob's (or practice partner's) failure to properly inform parents, identify measles in his patient and the parents narcissistic decision to leave their child unvaccinated and traipse him about, was $124 517.00 in order to prevent third generation transmission.  Cost to parents who refused post-exposure prophylaxis vaccination for their children and were placed in voluntary quarantine was ~$19 375.00.  Cost  to parents whose children were too young to be vaccinated and placed in voluntary quarantine was ~$37 200.00.

One would think this would be a humbling and educational experience for someone like Dr. Bob, but it wasn't.  In his 2008 blog about the San Diego measles outbreak, he callously dismissed the measles outbreak:

The recent measles outbreak (if you can call it that) in San Diego last month, in which twelve children came down with the illness after an unvaccinated family brought the disease back with them from Switzerland, raises awareness of a growing trend among families to decline certain vaccines.

Perhaps Dr. Bob could benefit from EpiRen's Epidemiology Night School where he discusses what constitutes an outbreak for Dr. Bob's pal Dr. Jay Gordon.

WHAT IS AN OUTBREAK?
Traditionally, an outbreak has been defined as "one case over the expected rate (or number) of cases for a given location in a period of time." In Minnesota, they have seen 22 cases over the last 14 years (22/14=1.6 cases per year in all Minnesota). Rounding up, we can say that two cases per year is what is expected. Three cases in 2011 would mean an outbreak. What was that in 2010, you ask? Well, 19 cases in 13 years give us a rate of 1.5 cases per year. It would also be an outbreak situation, especially if the three cases were epidemiologically linked. That information is not yet available from the MDH, but it will be interesting to read later on.

Let's look at the numbers; in 2005, the whole state of California had 4 cases, in 2006, California had 6 cases, in 2007, 5 total cases, in 2008, 14 cases, 12 of which were epidemiologically linked to the included index case and 4 cases occurred right in Dr. Bob's office.  The whole county of San Diego had not had a single measles outbreak since 1991.  All of California went back down to 9 total cases in 2009.  That was an outbreak as defined by epidemiology.  Unless Dr. Bob would like to claim that an average of 3 or 4 cases of measles occurs in his waiting room on an annual basis.  This is what he also callously claims regarding the ten month old infant infected in his waiting room and ended up in the hospital:

I believe our nation can tolerate a certain percentage of unvaccinated children without risking the overall public health in any significant way. Since most children are vaccinated, our nation has enough “herd immunity” to contain outbreaks like this one.
However, in the San Diego case, some infants caught measles before they were old enough to even be vaccinated. Fortunately, all cases passed without complications, as is usually the case with measles.

I beg to differ that the Campbell's son, hospitalised for 3 days and then several more days at home with constant monitoring is "uncomplicated".   Perhaps he hopes that no one will remember the children infected during this outbreak should any develop SSPE in the next few years.   Dr. Bob also doesn't get herd immunity, no need for scare quotes, herd immunity is real and assumes equal distribution of susceptibility to work.  He has helped to create the clustering effect which allowed foreign measles strains to spread until contact tracing and quarantining of exposed individuals was implemented by public health officials.  But that is just fine according to Dr. Bob:

Public health officials will be there to help clean up the mess that disease-friendly doctors like Dr. Bob create, instead of promoting prevention.  I am fully supportive of parents' right to choose vaccination schedules, however, choices need to be more responsible and "vaccine-friendly" doctors need to stop disseminating false information and validating poor vaccine choices.  To use the words of anti-vaxx spokesperson, Jenny McCarthy:

I do believe sadly it's going to take some diseases coming back to realize that we need to change and develop vaccines that are safe. If the vaccine companies are not listening to us, it's their f___ing fault that the diseases are coming back. They're making a product that's s___. If you give us a safe vaccine, we'll use it. It shouldn't be polio versus autism.

Except it isn't going to work out the way she thinks when some physicians and parents wilfully contribute to large gaps in herd immunity.  When a child does die or become permanently injured from measles, or a child is born with congenital rubella syndrome because the mother sat in a waiting room of someone like Dr. Bob Sears, or wild-type polio is ever diagnosed in the Western Hemisphere again, there will be a backlash.  Sears, Gordon and all of the other disease-friendly doctors won't get to re-define nomenclature and won't get to heartlessly disregard outcomes.

The next time you are looking for a measles party, or chicken pox, rubella, Hib, pertussis or mumps, no need to organise it with your local mummy forum, just stop by Dr. Sears' office or one of his disease-friendly associates offices on his list.  But you may want to go see a more competent physician if you actually want a proper diagnosis after the fact.  And even better, one who makes house-calls.

EDITED BY Catherina ON 6/6/2011 to add a comment from Dr. Bob made on his Facebook group:



Seems he lucked out there...

Dr. Bob Sears' Alternate Reality or Everyone is a Pharma Shill

On 17 February 2011, Dr. Bob Sears appeared on The Dr. Oz Show; the topic was "What Causes Autism". Dr. Oz packed the audience with mainly those who believe autism is caused by vaccines thus setting up all of the legitimate panel members (paediatricians) to be on the defensive. It was a live viewing, however, of how "alternative" practitioners get to play by their own rules enticing the audience, leaving those who remain true to the facts appearing unsympathetic and cold. One particular statement that Dr. Bob made was rather sensational and undoubtedly meant to be:

"Most of the vaccine studies that show no link between vaccines and autism are funded by the pharmaceutical companies."

Audience applause then:

"In fact, if you look at the 23 major studies that have shown no link, 18 of them are funded by big pharma."

Yes, he really did say "big pharma". Needless to say, I found this claim rather intriguing so I asked Dr. Bob which studies was he referring to:

On the Dr. Oz Show about autism a couple of weeks ago, you stated that most studies exonerating vaccines as the culprit for autism were pharma-funded, 18/23 to be exact. I'm very curious as to which 23 studies you were referring to.

He kindly replied:

Not counting studies labeled as “commentary,” since that isn’t original research, I count 18 out of 23. There may be some studies I didn’t include here, but these are most of them:

Studies that compared children who received vaccines with mercury with children who did not and found no association between vaccine mercury and autism:

1.) Association between thimerosal-containing vaccines and autism, Hviid A, et al., JAMA 2003;290(13):1763-66. Pharma-funded. http://jama.ama-assn.org/content/290/13/1763.long

2.) Mercury concentrations and metabolism in infants receiving vaccines containing thimerosal: a descriptive study, Pichichero M, et al., Lancet 2002;360(9347):1737-41. Pharma-funded. http://www.ncbi.nlm.nih.gov/pubmed/12480426

3.) Thimerosal and autism? Nelson K and Bauman M., Pediatrics 2003;111:674-79. Commentary. http://pediatrics.aappublications.org/cgi/content/full/111/3/674

4.) On-time vaccine receipt in the first year does not adversely affect neuropsychological outcomes, Smith M. and Woods C. Pediatrics 2010;125(6):1134-41. Pharma-funded. http://www.ncbi.nlm.nih.gov/pubmed/20498176

Studies that show autism continued to increase even after mercury was removed from vaccines:

5.) Thimerosal and the occurrence of autism: negative ecological evidence from danish population-based data, Madsen K, et al., Pediatrics 2003;112:604-606. Pharma-funded. http://pediatrics.aappublications.org/cgi/content/full/112/3/604?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=madsen&searchid=1&FIRSTINDEX=0&volume=112&issue=3&resourcetype=HWCIT

6.) Continuing increases in autism reported to california’s developmental services system, Schechter R, Grether, J., Arch Gen Psychiatry 2008;65(1):19-24.http://archpsyc.ama-assn.org/cgi/content/full/65/1/19

7.) Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations, Fombonne E, et al., Pediatrics 2006;118:e139-e150. Pharma-funded. http://pediatrics.aappublications.org/cgi/content/full/118/1/e139

Studies that examined the rates of autism compared to the cumulative levels of mercury in vaccines and found no association:

8.) Prenatal and infant exposure to thimerosal from vaccines and immunoglobulins and risk of autism, Price C. et al., Pediatrics 2010;126:656-64. Pharma-funded. http://www.ncbi.nlm.nih.gov/pubmed/20837594

9.) Safety of thimerosal-containing vaccines: a two-phased study of computerized health maintenance organization database, Verstraeten T. et al., Pediatrics 2003;112:1039-48. Pharma-funded. http://pediatrics.aappublications.org/cgi/content/full/112/5/1039

10.) Neuropsychological performance 10 years after immunization in infancy with thimerosal-containing vaccines, Tozzi A, et al., Pediatrics 2009;123:475-82. http://pediatrics.aappublications.org/cgi/content/full/123/2/475

11.) Autism and thimerosal-containing vaccines: lack of consistent evidence for an association, Stehr-Green P., Am J Prev Med 2003;25(2):101-106. Pharma-funded. http://www.ncbi.nlm.nih.gov/pubmed/12880876

12.) Thimerosal exposure in infants and developmental disorders: a prospective cohort study in the united kingdom does not support a causal association, Heron J, et al., Pediatrics 2004;114:577-83. Pharma-funded. http://pediatrics.aappublications.org/cgi/content/full/114/3/577

13.) Early thimerosal exposure and neuropsychological outcomes, Thompson W, et al., N Engl J Med 2007;357:1281-92. Pharma-funded. http://www.nejm.org/doi/full/10.1056/NEJMoa071434#t=articleTop

14.) Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations, Fombonne E, et al., Pediatrics 2006;118:e139-e150. Pharma-funded. http://pediatrics.aappublications.org/cgi/content/full/118/1/e139

Research comparing autism rates in children who did and did not receive the MMR vaccine and found no increased risk of autism:

15.) A population-based study of measles, mumps, and rubella vaccination and autism, Madsen KM, et al. N Engl J Med 2002;347(19):1477-82. Pharma-funded. http://www.nejm.org/doi/full/10.1056/NEJMoa021134#t=articleTop

16.) No effect of MMR withdrawal on the incidence of autism: a total population study, Honda H, et al., J Child Psychology and Psychiatry 46:6 (2005); 572-79. Pharma-funded. http://www.ncbi.nlm.nih.gov/pubmed/15877763

Research that duplicated Wakefield’s study and found no association between MMR and autism:

17.) Lack of association between measles virus vaccine and autism with enteropathy: a case-control study, Hornig M, et al., PLoS ONE 2008;3(9):e3140. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526159/?tool=pubmed

Studies showing no evidence of a temporal relationship between MMR vaccine and autism:

18.) MMR vaccination and pervasive developmental disorders: a case-control study, Smeeth L, et al., Lancet 2004; 364:963-69. Pharma-funded. http://www.ncbi.nlm.nih.gov/pubmed/15364187

19.) Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations, Fombonne E, et al., Pediatrics 2006;118:e139-e150. Pharma-funded. http://pediatrics.aappublications.org/cgi/content/full/118/1/e139

20.) No evidence for a new variant of measles-mumps-rubella-induced autism, Fombonne E and Chakrabarti S, Pediatrics 2001;108:e58. Pharma-funded. http://www.ncbi.nlm.nih.gov/pubmed/11581466

21.) No evidence for links between autism, MMR, and measles virus, Chen W. et al., Psychological Medicine 2004;34(3):543-53. http://www.ncbi.nlm.nih.gov/pubmed/15259839

22.) Neurologic disorders after measles-mumps-rubella vaccination, Mäkelä A, et al., Pediatrics 2002;110:957-63. Pharma-funded. http://pediatrics.aappublications.org/cgi/content/full/110/5/957

23.) Association of autistic spectrum disorder and the measles, mumps, and rubella vaccine, Wilson K. et al., Arch Pediatr Adolesc Med 2003;157:628-34. Commentary. http://archpedi.ama-assn.org/cgi/content/full/157/7/628

24.) Vaccines for measles, mumps and rubella in children, The Cochrane Database of Systematic Reviews 2005; issue 4. Commentary. http://www.ncbi.nlm.nih.gov/pubmed/16235361

Studies that show no link between MMR and autism or gastrointestinal disease:

25.) MMR vaccine and autism: an update of the scientific evidence, DeStefano F., Thompson W., Centers for Disease Control, Expert Review of Vaccines 2004;3(1):19-22. Commentary. http://www.ncbi.nlm.nih.gov/pubmed/14761240

26.) Measles vaccination and antibody response in autism spectrum disorders, Baird G, et al., Arch Dis Child 2008;93:832-37. Pharma-funded. http://www.ncbi.nlm.nih.gov/pubmed/18252754

27.) Unintended events following immunization with MMR: a systematic review, Jefferson T. et al., Vaccine 2003;21(25-26):3954-60. Commentary. http://www.ncbi.nlm.nih.gov/pubmed/12922131

28.) A case-control study of measles vaccination and inflammatory bowel disease, The East Dorset Gastroenterology Group, Feeney M. et al., Lancet 1997;350(9080):764-66. http://www.ncbi.nlm.nih.gov/pubmed/9297995

Miscellaneous

29.) Immunization Safety Review: Vaccines and Autism, Immunization Safety Review Committee, Washington, DC: Institute of Medicine of the National Academies, 2004. Commentary. http://www.ncbi.nlm.nih.gov/books/NBK25344/

Research can be funded in numerous ways, for example, government institutions such as the NIH or CDC, special interest groups such as Autism Speaks or Autism Science Foundation, charitable/philanthropic organisations such as The David & Lucile Packard Foundation or Wellcome Trust and of course, industry such as pharmaceutical or agricultural companies. When Dr. Bob states, "funded by pharmaceutical companies", that has a very specific meaning, that the study was funded by pharmaceutical companies. Let's look at the funding sources for those he tagged as "pharma-funded":

1.) Association between thimerosal-containing vaccines and autism, Hviid et al.
Author Affiliations: Danish Epidemiology Science Centre, Department of Epidemiology Research (Messrs Hviid, Wohlfahrt, and Dr Melbye) and Medical Department (Dr Stellfeld), Statens Serum Institut, Copenhagen, Denmark.
Funding Statement: This study was supported by grant 11 from the Danish National Research Foundation and grant 22-02-0293 from the Danish Medical Research Council.

The Danish System is unique in that they have universal healthcare; Statens Serum Institut (SSI) is a public enterprise that operates under the Danish Ministry of Health. SSI has a division which develops vaccines and is essentially, a non-profit. SSI also has divisions which operate much like the CDC in the U.S. These divisions are where the authors of this study are employed. A comprehensive explanation of SSI's structure can be read here. This is not "big pharma" by any stretch of the imagination.

2.) Mercury concentrations and metabolism in infants receiving vaccines containing thimerosal: a descriptive study, Pichichero M, et al.
Author Affiliations: Department of Microbiology/Immunology, University of Rochester, Rochester, New York, NY, USA.
Conflict of Interest: None declared.
Funding Statement: The investigation was funded by the US National Institutes of Health (NIH), Bethesda, MD, under contract 1 AF-45248.

4.) On-time vaccine receipt in the first year does not adversely affect neuropsychological outcomes, Smith M. and Woods C.
Author Affiliations: University of Louisville School of Medicine, Division of Pediatric Infectious Diseases, 571 S Floyd St, Suite 321, Louisville, KY 40202, USA.
Conflicts of Interest: Drs Smith and Woods are or have been unfunded subinvestigators for cross-coverage purposes on vaccine clinical trials for which their colleagues receive funding
from Wyeth, Sanofi Pasteur, GSK, MedImmune, and Novartis; and Dr Woods has received honoraria for speaking engagements from Merck, Sanofi Pasteur, Pfizer, and MedImmune and has received research funding from Wyeth and Sanofi Pasteur.
Funding Statement: This study was conducted without funding from any company (e.g., vaccine manufacturer) or agency (e.g., the CDC). We conducted this study on our own after requesting and receiving the publicly available data that were used for the analyses. Our unrelated interactions with vaccine manufacturers have been appropriately disclosed for full transparency in accordance with our own ethical standards as well as formal guidelines from the Academy of Pediatrics and the University of Louisville.

This is what Dr. Bob had to say about the study when he was asked (he also copied a communication from Dr. Rosen included in the preceding link):

Major flaws by Dr. Bob Sears - posted on 5/25/2010
Let me first say I haven't read it yet. Too busy in office last few days. But here are three observations: 1 - they excluded kids with autism from the study (DUH! - that's the type of kids you'd want to include in this!)
2. Hugely funded by pharmaceutical companies - the list of conflict of interest is quite long. Publishing a study like this with pharma funding is 100% worthless - the only people who will believe it are those who don't mind conflicts of interest.
3. Here's a comment from one of a doctor in the AAP who heads up one of the AAP divisions: this is the letter he wrote the journal:

"Dear Sirs,

I read with great interest Smith and Woods article, "On-time Vaccine Receipt in the First Year Does Not Adversely Affect Neuropsychological Outcomes." This issue is of paramount importance in clinical primary care practice today. However, I was dismayed by two factors within minutes of reading the piece. One, of perhaps lesser importance, in the Results Section, the numbers, simply put, do not add up. If all of the subjects are added as listed, a total of 1037 (not 1047) is obtained. Furthermore, the percentages are incorrect as listed. The final group (311) is in fact 30% of the incorrect total, not 20% as listed. It always concerns me and forces me to question the validity of the other findings when a mistake like this is notable. In any case, the finding that approximately 50% (depending on the true numbers) received an alternative vaccine schedule, even as long ago as 1993-1997 is of interest.

Of greater concern to me, personally, is the Financial Disclosure listings. It is very difficult in this day and age to review the authors' conclusions without considering their considerable potential biases given where their funding comes from. I believe every known vaccine manufacturer is listed on the payroll. Until we have well-done, conflict- free published research on this topic, both the public and skeptical physicians must continue to look for honest answers."

Dr. Bob didn't even read the study, let alone read the response that Dr. Rosen received about funding sources (self-funded) from the authors and absolutely no pharmaceutical funding. He doesn't even grasp that Dr.s Smith and Woods used the data set from Thompson et al. (13), which specifically excluded autism and explained why. This is just Dr. Bob being intentionally misleading so he doesn't have to confront any evidence that is antithetical to his "trademark alternative vaccine schedule".

5.) Thimerosal and the occurrence of autism: negative ecological evidence from danish population-based data, Madsen K, et al.
Author Affiliations: Danish Epidemiology Science Centre, Department of Epidemiology and Social Medicine, University of Aarhus, Denmark
Institute for Basic Psychiatric Research, Department of Psychiatric Demography, Psychiatric Hospital in Aarhus, Risskov, Denmark
National Centre for Register-Based Research, University of Aarhus, Aarhus, Denmark
State Serum Institute, Department of Medicine, Copenhagen, Denmark
Funding Statement: The activities of the Danish Epidemiology Science Centre and the National Centre for Register-Based Research are funded by a grant from the Danish National Research Foundation. This study was supported by the Stanley Medical Research Institute. No funding sources were involved in the study design.

7.) Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations, Fombonne E, et al.
Author Affiliations: Department of Psychiatry, McGill University, Montreal Children's Hospital, Montreal, Quebec, Canada
Lester B. Pearson School Board, Montreal, Quebec, Canada
Conflicts of Interest: In the United Kingdom, Dr Fombonne has provided advice on the epidemiology and clinical aspects of autism to scientists advising parents, to vaccine manufacturers, and to several government committees between 1998 and 2001. Since June 2004, Dr Fombonne has been an expert witness for vaccine manufacturers in US thimerosal litigation.
Funding Statement: None of his research has ever been funded by the industry.

8.) Prenatal and infant exposure to thimerosal from vaccines and immunoglobulins and risk of autism, Price C. et al.
Author Affiliations: Abt Associates Inc, Cambridge, Massachusetts;
National Center for Chronic Disease Prevention and Health Promotion, Immunization Safety Office, and Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia;
Division of Research, Kaiser Permanente Northern California, Oakland,California;
Department of Psychiatry and Behavioral Sciences, Kaiser Permanente ASD Center San Jose Northern California Region, Stanford University, Palo Alto, California;
Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts;
Southern California Kaiser Permanente, and Center for Vaccine Research, University of California, Los Angeles, California; and
Center for Health Research Southeast, Kaiser Permanente, Atlanta, Georgia
Funding Statement: This work was supported by a contract from the CDC to America’s Health Insurance Plans and via America’s Health Insurance Plans subcontracts to Abt Associates Inc; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School; Southern California Kaiser Permanente, and Center for Vaccine Research, University of California Los Angeles; and Division of Research, Kaiser Permanente Northern California.

Ironically, this is the study that Dr. Bob's colleague, Sally Bernard of SafeMinds participated in.

9.) Safety of thimerosal-containing vaccines: a two-phased study of computerized health maintenance organization database, Verstraeten T. et al.
Author Affiliations: Epidemic Intelligence Service Program, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Vaccine Safety and Development Activity, Epidemiology and Surveillance Division, National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia
University of Washington and Group Health Cooperative of Puget Sound, Seattle, Washington
Center for Child Health Care Studies, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, and Division of General Pediatrics, Children’s Hospital, Boston, Massachusetts
Kaiser Permanente Vaccine Study Center, Oakland, California
Funding Statement: None declared.

Ironically, this study group invited Dr. Bob's colleague, Lyn Redwood of SafeMinds to review the findings.

11.) Autism and thimerosal-containing vaccines: lack of consistent evidence for an association, Stehr-Green P. et al.
Author Affiliations: Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA.
National Board of Health and Welfare (Tull), Stockholm, SwedenStatens Serum Institut (Stellfeld), Copenhagen, Denmark
National Centre for Register-Based Research (Mortenson), Aarhus, Denmark
National Immunization Program, Centers for Disease Control and Prevention (Simpson), Atlanta, Georgia, USA
Funding Statement: Financial support for the compilation of the data used in this investigation and the preparation of this report was provided by the National Immunization Program, Centers for Disease Control and Prevention. We are grateful to Victoria Romanus of the Swedish Institute for Infectious Disease Control, Ingrid Trolin of the Swedish Medical Products Agency, Anne-Marie Plesner and Peter Andersen of the Danish Statens Serum Institut, and Roger Bernier and Susan Chu of the Centers for Disease Control and Prevention for their contributions in the design and conduct of this investigation, and in the preparation and review of this manuscript.

12.) Thimerosal exposure in infants and developmental disorders: a prospective cohort study in the united kingdom does not support a causal association, Heron J, et al.
Author Affiliations: Unit of Paediatric and Perinatal Epidemiology, Department of Community-Based Medical Sciences, University of Bristol, Bristol, United Kingdom
Funding Statement: Financial support for the establishment of the ALSPAC cohort was provided by the Medical Research Council, the Wellcome Trust, the UK Department of Health, the Department of the Environment, and DfEE, the National Institutes of Health, and a variety of medical research charities and commercial companies. Funding for this study was provided by the Department of Health (Ref VIE 134/1).

13.) Early thimerosal exposure and neuropsychological outcomes, Thompson W, et al.
Author Affiliations: From the Influenza Division and Immunization Safety Office , Centers for Disease Control and Prevention, Atlanta;
Abt Associates, Cambridge, MA;
Group Health Center for Health Studies, Seattle;
the Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston;
Kaiser Permanente Division of Research and Vaccine Study Center, Oakland, CA;
UCLA Center for Vaccine Research, Torrance, CA;
Southern California Kaiser Permanente, Los Angeles;
RTI International, Atlanta; and
Stanford University, Palo Alto, CA.
Conflicts of Interest: Dr. Thompson reports being a former employee of Merck; Dr. Marcy, receiving consulting fees from Merck, Sanofi Pasteur, GlaxoSmithKline, and MedImmune; Dr. Jackson, receiving grant support from Wyeth, Sanofi Pasteur, GlaxoSmithKline, and Novartis, lecture fees from Sanofi Pasteur, and consulting fees from Wyeth and Abbott and serving as a consultant to the FDA Vaccines and Related Biological Products Advisory Committee; Dr. Lieu, serving as a consultant to the CDC Advisory Committee on Immunization Practices; Dr. Black, receiving consulting fees from MedImmune, GlaxoSmithKline, Novartis, and Merck and grant support from MedImmune, GlaxoSmithKline, Aventis, Merck, and Novartis; and Dr. Davis receiving consulting fees from Merck and grant support from Merck and GlaxoSmithKline. No other potential conflict of interest relevant to this article was reported.
Funding Statement: Supported by the CDC.

14.) Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations, Fombonne E, et al.
Author Affiliations: Department of Psychiatry, McGill University, Montreal Children's Hospital, Montreal, Quebec, Canada
Lester B. Pearson School Board, Montreal, Quebec, Canada
Conflict of Interest: In the United Kingdom, Dr Fombonne has provided advice on the epidemiology and clinical aspects of autism to scientists advising parents, to vaccine manufacturers, and to several government committees between 1998 and 2001. Since June 2004, Dr Fombonne has been an expert witness for vaccine manufacturers in US thimerosal litigation.
Funding Statement: None of his research has ever been funded by the industry.

15.) A population-based study of measles, mumps, and rubella vaccination and autism, Madsen KM, et al.
Author Affiliation: Danish Epidemiology Science Center, Department of Epidemiology and Social Medicine, Århus, Denmark;
Danish Epidemiology Science Center, Department of Epidemiology Research, Statens Serum Institute, Copenhagen, Denmark; and
National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta.
Funding Statement: Supported by grants from the Danish National Research Foundation; the National Vaccine Program Office and National Immunization Program, Centers for Disease Control and Prevention; and the National Alliance for Autism Research.

16.) No effect of MMR withdrawal on the incidence of autism: a total population study, Honda H, et al.
Author Affiliations: Yokohama Rehabilitation Center, Yokohama, Japan;
Institute of Psychiatry, London, UK
Funding Statement: None declared.

18.) MMR vaccination and pervasive developmental disorders: a case-control study, Smeeth L, et al.
Author Affiliations: Department of Epidemiology and Population Health;
Department of Infectious and Tropical Diseases ;
London School of Hygiene and Tropical Medicine, London, UK;
Department of Psychiatry, McGill University, Montreal Children’s Hospital, Canada;
and Institute of Psychiatry, Kings College, London, UK
Conflicts of Interest: L Smeeth, C Cook, L Heavey, L C Rodrigues, and P G Smith have no conflicts of interest. E Fombonne has provided advice on the epidemiology and clinical aspects of autism to scientists advising parents, to vaccine manufacturers (for a fee), and to several government committees. A J Hall received a financial contribution from Merck towards research on hepatitis B vaccination in 1998. He is also a member of the Joint Committee on Vaccines and Immunisation (2002–present).
Funding Statement: The study was funded by the UK Medical Research Council. L Smeeth is supported by a Medical Research Council Clinician Scientist Fellowship.

19.) Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations, Fombonne E, et al.
Duplicate of (14)

20.) No evidence for a new variant of measles-mumps-rubella-induced autism, Fombonne E and Chakrabarti S
Author Affiliation: Institute of Psychiatry, Department of Child and Adolescent Psychiatry, King’s College London, London, United Kingdom;
Child Development Center, Central Clinic, Stafford, United Kingdom.
Funding Statement: None declared.

22.) Neurologic disorders after measles-mumps-rubella vaccination, Mäkelä A, et al.
Author Affiliations: Hospital for Children and Adolescents, Helsinki University Central Hospital, Helsinki, Finland
Department of Infectious Disease Epidemiology, National Public Health Institute, Helsinki, Finland.
Funding Statement: Dr Mäkelä was partially supported by a grant from Merck & Co.

26.) Measles vaccination and antibody response in autism spectrum disorders, Baird G, et al.
Author Affiliation: Newcomen Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, UK;
Biostatistics Group, Division of Epidemiology & Health Sciences, University of Manchester, Manchester, UK;
Department of Child and Adolescent Psychiatry, Institute of Psychiatry, King’s College London, UK;
Behavioural and Brain Sciences Unit, UCL Institute of Child Health, London, UK;
Department of Paediatrics, John Radcliffe Hospital, University of Oxford, Oxford, UK;
School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK;
Chatswood Assessment Centre, Sydney, New South Wales, Australia;
National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, UK;
Virus Reference Department, Centre for Infections, Health Protection Agency, London, UK
Conflicts of Interest: MA and DB have given unpaid advice to lawyers in MMR and MR litigation. GB has acted as an occasional expert witness for the diagnosis of autism. AP receives royalties from SCQ and ADOS-G instruments. PBS has acted as an expert witness in the matter of MMR/MR vaccine litigation. All other authors have no conflicts of interest.
Funding Statement: he study was funded by the Department of Health, the Wellcome Trust, the National Alliance for Autism Research (NAAR) and Remedi. The sponsors of the study had no role in study design, data collection, data analysis, data interpretation or writing
of the report. The corresponding author had full access to all the data in the study and final responsibility for the decision to submit for publication.

Of the 18 studies that Dr. Bob declared are pharma-funded, 1 (22) is partially funded by Merck, three studies (9, 16 and 20) don't have funding statements and 1 (19) is a duplicate of (14). That leaves 13 studies with no pharmaceutical funding whatsoever, confirmed. I already knew this so I offered Dr. Bob the chance to rectify his "mistake":

I really do wish to thank you for answering me. In doing so, I would like to extend you the courtesy of retracting your statements that, "Most of the vaccine studies that show no link between vaccines and autism are funded by the pharmaceutical companies" and, "In fact, if you look at the 23 major studies that have shown no link, 18 of them are funded by big pharma." before I write about this.

However, instead of making the honest gesture to retract his demonstrably false statements, Dr. Bob "clarifies":

Clarification by Dr. Bob - posted on 3/10/2011

A quote from the beginning of the Fombonne study:
Since June 2004, Dr Fombonne has been an expert witness for vaccine manufacturers in US thimerosal litigation.

The qualifications I use to determine if a study is pharma-funded is 1. The research is directly funded by pharma, or 2, the researchers involved have received money from pharmaceutical companies for services rendered, or 3. The researchers in the past have had other studies funded by pharma (I'm don't think this last one applies anywhere here, but I don't remember now).

Because Dr. Fombonne has been an expert witness in defense of the pharmaceutical companies, this creates a clear financial and professional conflict of interest.

I know that none of this would matter to some of you on this board, but I think it matters to most parents in general.

And this goes both ways. Some of the doctors who HAVE found a link between autism and vaccines in their research have testified AGAINST pharma on behalf of vaccine injury claimants. I also consider that a conflict of interest in their research.

But of course! Create an overreaching, blatantly dishonest, weasel-worded definition for what he meant; pure truthiness. He devises an alternate rendering in order to set up the premise should "big pharma" even fart in the general direction of an investigator, he can label their study as "pharma-funded". Even by his own tortured criteria, he can't claim that the three studies with no funding declaration are "pharma-funded" but yet he does. He doesn't even read these studies; he doesn't know how but only knows that they don't concur with his pre-conceived notions (and his bread and butter). How does he explain that these so-called "pharma-funded" studies' results are concordant with those that he hasn't deemed "pharma-funded"? He can't.

As for this statement:

And this goes both ways. Some of the doctors who HAVE found a link between autism and vaccines in their research have testified AGAINST pharma on behalf of vaccine injury claimants. I also consider that a conflict of interest in their research.

It's a right load of bollocks. His Vaccine Book is rife with "studies" by the Geiers, Wakefield, Classen, Goldman, Yazbak and Bradstreet, all with conflicts of interest, businesses that profit from "vaccine damage", and/or appearances as "expert witnesses" for petitioners in the NVICP. Why he still considers Andy (Wakefield) a close friend and stands behind his research, not to mention Dr. Bob's own flagrant conflicts of interest. As a DAN! doctor, he thrives on hawking "vaccines cause autism" and promoting fear about vaccines helps to keep his books, products and services selling. He clearly has a financial and personal investment in denying the legitimacy of any studies that don't support his paradigm.

Do some authors have conflicts of interest? Yes they do and their declarations allow the readers of their studies to properly assess their value and consider replication of other studies. Had Dr. Bob stated that some of these authors have conflicts of interest, he would have made a factual statement, but he also wouldn't have made the same impact on the audience and I believe he knows that, which is why he defers to truthiness. It is a predictable tactic for the deceptive "vaccine safety" party line pushers to take. Furthermore, he only includes about half of the list of studies that cannot find a vaccine-autism association; hand-picking only those he believes he can apply his crooked standard to.

It is also worth noting Dr. Bob's dishonest/incompetent labelling of studies 3, 23, 24, 25, 27 and 29 as "commentaries". Again, a word with a very specific meaning when referring to scientific publications. For example, Pediatrics defines commentaries as follows:

Abstract length: no abstract
Article length: 400 to 800 words
Commentaries are opinion pieces consisting of a main point and supporting discussion. These contributions usually pertain to and are published concurrently with a specific article; the commentary serves to launch a broader discussion of a topic. Commentaries may address general issues or controversies in the field of pediatrics.

Nearly all medical/scientific journals will have a commentary or editorial section and they are rather consistent. What Dr. Bob labelled as "commentaries" are actually reviews, systematic reviews or meta-analyses and only one actual commentary and it is positively cloddish that he either doesn't know this or is too morally bankrupt to care. A review, as the name implies is an article that provides a more generalised, critical review of a specific topic. They are almost always solicited and peer-reviewed in the same manner as original research. They are very useful, mostly written by top experts in their respective fields (the quality, of course, depends upon the quality of the journal) that provide a good overview although can still be subject to author bias. Systematic reviews and meta-analyses can be very powerful study designs as explained in this study module by The Cochrane Collaboration. I doubt Dr. Bob has the desire to actually learn something contrary to his witless dogma by reading this, but "systematic review" in the titles of the damn studies should have tipped him off. For him to try and pass off an Institute of Medicine - Immunization Safety Review as a commentary just begs for a rhetorical drubbing.

Dr. Bob is nothing more than a self-styled marketeer, a medico last. He has managed to parlay some business acumen, M.D. credentials and family name into a business that obfuscates his mediocre medical skills and complete oblivion of science. He is influencing public health and has absolutely no competence to do so.

Paediatricians need to be more proficient at countering his fabrications when both dealing with parents and confronting him in the media. Parents' fears can be acknowledged without being validated and sadly, paediatricians have to make an effort to undo the damage that the likes of Dr. Bob have done on their own time while he makes a living off of generating fear with patently false information.

Wakefield is a Fraud

It isn't exactly news to those of us who frequent blogs where Brian Deer posts but it's now official. This evening, CNN reported on the first instalment in the British Medical Journal (BMJ) of Mr. Deer's exposé of how Andrew Wakefield falsified medical records of the 12 children reported in the now retracted, 1998 Lancet study. CNN's first report by Parker and Spitzer caused notorious anti-vaxxer, J.B. Handley of Generation Rescue and a contributor to Age of Autism to squirm in his seat and dodge the hard, albeit straightforward questions posed to him.

The second was by Anderson Cooper who interviewed Andy Wakefield about the BMJ editorial on AC360°. Wakefield was clearly unnerved and uncharacteristically frenzied by Mr. Cooper's direct questioning about his fraud, conflicts of interest and associations with the legal aid supporting the Lancet study. True to form, Wakefield lied and stated he declared his conflicts of interest, did not receive any money from the MMR litigation team and that his work, "has been replicated in five countries around the world".

Brian Deer's feature article was followed up by another scathing editorial by the editors of BMJ.

In a series of articles starting this week, and seven years after first looking into the MMR scare, journalist Brian Deer now shows the extent of Wakefield’s fraud and how it was perpetrated (doi:10.1136/bmj.c5347). Drawing on interviews, documents, and data made public at the GMC hearings, Deer shows how Wakefield altered numerous facts about the patients’ medical histories in order to support his claim to have identified a new syndrome; how his institution, the Royal Free Hospital and Medical School in London, supported him as he sought to exploit the ensuing MMR scare for financial gain; and how key players failed to investigate thoroughly in the public interest when Deer first raised his concerns.11

Wakefield altered medical records of the 'Lancet 12' to the extent that none of the children's reported results were concordant with their medical records as summed up here:

How the link was fixed

The Lancet paper was a case series of 12 child patients; it reported a proposed “new syndrome” of enterocolitis and regressive autism and associated this with MMR as an “apparent precipitating event.” But in fact:

• Three of nine children reported with regressive autism did not have autism diagnosed at all. Only one child clearly had regressive autism

• Despite the paper claiming that all 12 children were “previously normal,” five had documented pre-existing developmental concerns

• Some children were reported to have experienced first behavioural symptoms within days of MMR, but the records documented these as starting some months after vaccination

• In nine cases, unremarkable colonic histopathology results—noting no or minimal fluctuations in inflammatory cell populations—were changed after a medical school “research review” to “non-specific colitis”

• The parents of eight children were reported as blaming MMR, but 11 families made this allegation at the hospital. The exclusion of three allegations—all giving times to onset of problems in months—helped to create the appearance of a 14 day temporal link

• Patients were recruited through anti-MMR campaigners, and the study was commissioned and funded for planned litigation

It is refreshing to witness that the very media who fueled Wakefield's MMR-autism scare and help to create a manufactroversy by providing false balance with appearances by vaccine-autism cranks, are now doing some due diligence by investigating the claim a bit more thoroughly and positing incisive questions to those making the outrageous claims. Sadly, there will always be some media types that will continue to give the vaccine-autism cranks some air-time in the name of 'balance' but it definitely appears as though they will be far and few between and not particularly important from an ethical journalistic point of view.

The MMR-autism scare is based upon verifiable, scientific fraud. Millions of dollars and countless hours have been consumed to investigate this claim and none has been found. Then again, it's rather difficult to find evidence of causation when the original claim was completely and utterly falsified for personal and financial gain. Any practitioner who would still perpetuate Wakefield's claim and support him should be viewed as dubious, at best and a charlatan, at worst.

Policy vs. Evidence: Part 1, personal

I have been planning a small series of posts for a while looking at vaccine policy vs. evidence for vaccine policy (i.e. when which vaccine are recommended for which population). This had originally been triggered by the flu vaccine recommendation for under 2 year olds and criticism thereof and some anecdotes on the handling of vaccine recommendations in my own life and online. I will kick off this series with a personal admission:

I am a vaccine refuser/alternatively vaccinating parent - our older child's school holds a current vaccination "non consent" form.

That is the short story. The long story is a little more complex. In the UK, children get their booster shots in school. They are paid for by the National Health Service. So last year, we got a letter home, asking us for consent to a dT/IPV (Diphtheria, Tetanus, inactivated Polio vaccine) booster. Well, it was 9 years after the dT pre-school booster, so the dT was a very good idea. The IPV however, we did not quite see as critical. Polio has been eradicated in the Western Hemisphere (this was before the Russian polio import from Tajikistan. Both children had had 4 polios. More importantly, however, I wanted the kids to be boosted for pertussis (routine on the German teen schedule). First of all, we know that pertussis immunity wanes, whether you had the shots (see also here) or coughed for it, then we know that the booster works for teens, adolescent and adult vaccination was likely to be cost effective, and finally, I had pertussis as a 15 year old (from babysitting an unvaccinated toddler) and I was not keen on anyone in the family living through a summer of relentless choughing. Pertussis is not nick-named "100 day cough" for nothing.

This was an interesting experience. The nurses from the school immunisation service could not help me with a dTaP (aP = acellular Pertussis) or dTaP/IPV. They were nice, though. The GP referred us to the health visitor, who only does babies and toddlers. The nurse from the travel vaccine section of our GP practise hung up on me after I had explained our wishes, with very little patience for something extraordinary. So finally, we landed in a private practise, one of those places that used to make money by selling the single M(easles), M(umps) and R(ubella) vaccines (call me hypocrite). While the nurse was clueless, she was exquisitely friendly, she did not hang up on me, so I could explain which vaccine we wanted, then explained to their resident GP that while that particularly vaccine was not licensed for kids over 10 years in the UK, it was in a lot of other countries (German pdf; I know because DH and I got the same vaccine in 2005). And eventually, after a reasonable office fee and a surprisingly cheap booster shot (£5 a pop), the whole family was back on track. Phew. So when the school sent out another consent form this year, we responded back with another non-consent (and an explanation why we did not consent).

In the end, the whole procedure was extremely sobering. Our decision to vaccinate our school children against pertussis was totally backed by evidence, biologically relevant and followed European recommendations, just not the UK's. In our opinion, the current UK policy was lagging behind the available evidence, even studies from the UK. It required a fair amount of perseverance and the luxury of some dispensable money to protect our children what we considered adequately.

Ho! How did I miss this?

A poster asked in the comment section of our blog, whether the index patient in the San Diego measles outbreak had been a patient of "Dr. Bob" Sears. I recalled that Bob had been asked that directly on his board:

San Diego meales outbreak by San Diego mommy - posted on 3/26/2009

Someone told my that the child who started the San Diego measles outbreak last year was one of Dr Bob's unvaccinated patients. Is that true? That is so sad for the families affected by the outbreak, especially for the babies that were too young to be protected by the vaccine.

and Bob had answered in his usual flippant and evasive manner:

Ya, she wanted the MMR, but I wouldn't give it to by Dr. Bob - posted on 3/27/2009

So, it's totally my fault that the outbreak happened.

No, seriously, I do know who the family is and have interacted with them. I'll leave it at that, since it doesn't actually matter if they were actually my patient or not.

Seth Mnookin, the author of the soon to be released "The Panic Virus" pointed me to an Orange County Register piece that is much more candid than Dr. Bob:

An unvaccinated 7-year-old boy traveled to Switzerland and unknowingly contracted the virus. Almost 100 children (including babies who were too young for the MMR vaccine) were quarantined or hospitalized after they were exposed at the pediatrician’s office, Whole Foods or day care. In all, 11 children caught the measles. As it turns out, the boy who spread measles is a patient of Dr. Bob Sears

(my bold)

Dr. Bob himself downplays the severity of the situation in his 2008 blog by saying:

The recent measles outbreak (if you can call it that) in San Diego last month,

(my bold)

Fact check for Dr. Bob:

A recent study by researchers on the role of vaccine refusal in this outbreak was staggering: 839 people were exposed, 11 additional measles cases were reported (all in unvaccinated children); one infant, too young to be vaccinated, had to be hospitalized. At a time when the state of California is in devastating financial straits, it cost San Diego serious health care dollars: $10,376 per case, for a total of $124,517 (and the hospitalized infant's bill was nearly $15,000). Forty-eight children too young to be vaccinated were quarantined for several weeks, meaning parents had to miss work and wages at an average cost of $775 per child.

In his blog, Dr. Bob claims:

Fortunately, all cases passed without complications, as is usually the case with measles.

Lost in the depth of his own board is the reality check by Wilbert Mason, MD

Minimization of the effects of measles by Wilbert Mason MD - posted on 4/3/2008

As a pediatric infectious disease physician I feel I must comment on statements made in your March 27th commentary on the New York Times article. First, you infer that the cases in San Diego did not constitute an outbreak ("...if you can call it that..."). This is a highly contagious infection that spreads by small droplets that remain suspended in a closed room for over an hour. Indeed, 4 of the cases acquired the infection just by being in the pediatrician’s office at the same time as the first case. Three of these were infants and one of them had to be admitted to the hospital for dehydration.
Elsewhere you have observed that “all of the cases of measles passed without complications, as is usually the case with measles”. Let me share with you our experience with measles at Childrens Hospital Los Angeles during the measles epidemic in 1990. We diagnosed 440 cases between January 1st and June 30th. Of these cases 195 (44%) had to be admitted for one or more complications of measles. We documented the complications in all 440 cases and they included 63% with ear infections, 45% with diarrhea, 39% with dehydration, 36% with pneumonia, 19% with croup, and about 3% with other bacterial infections. Three children died all of pneumonia. Measles is not a trivial infection as you inferred. We would not be having a debate about vaccines at all if people realized the tremendous costs in suffering and human life we incurred before vaccines became available. To adequately protect a population against measles >90% of the population must be effectively immunized against the disease. If individuals defer vaccines as you suggest we will rapidly fall below that level putting large numbers of infants and children at risk of an outbreak if measles is introduced into the community. This is a free country but we should all feel some responsibility to our fellow citizens and their children.

Thank you Dr. Mason, that says it all, really, about the irresponsible behaviour of Dr. Bob Sears (and the patients' parents who believe him).

Measles - actual - not hypothetical

another Dr. Bob "gem", I am afraid.

A poster on Bob's forum asked:

dr. sears hypothetical question... by - posted on 12/10/2010

my kids are 3 and a half and 1- both boys. we live in ny, and they havent had any vaccines. i would like to eventually travel with them, normal family spots- carribean, europe.... would you vax if you were me, and if so, which would you do? thanks!

Dr. Bob relishes these opportunities - here is his answer:

DR. Bob Answers by Dr. Bob - posted on 12/10/2010

Hypothetically, if I was a doctor answering a forum question pretending to be the person asking the question, my answer would be that I wouldn't do any vaccines just for disease coverage for the type of vacation travel that you, I mean "I", would be doing.

The OP thinks that is a reason to "lol" - I think it is a reason to facepalm. Unvaccinated children travelling out of the US, for example to Europe, are the major source of importation of measles - last demonstrated by the San Diego outbreak.

The index patient was an unvaccinated boy aged 7 years who had visited Switzerland with his family, returning to the United States on January 13, 2008. He had fever and sore throat on January 21, followed by cough, coryza, and conjunctivitis.

.../...

During January 31--February 19, a total of 11 additional measles cases in unvaccinated infants and children aged 10 months--9 years were identified. These 11 cases included both of the index patient's siblings (rash onset: February 3), five children in his school (rash onset: January 31--February 17), and four additional children (rash onset: February 6--10) who had been in the pediatrician's office on January 25 at the same time as the index patient. Among these latter four patients, three were infants aged over 12 months. One of the three infants was hospitalized for 2 days for dehydration; another infant traveled by airplane to Hawaii on February 9 while infectious.

Great job, who ever had suggested to the parents of that index case that it was ok to travel to Switzerland (in the middle of an ongoing measles outbreak with more than 3400 cases, 8 encephalitis and a pediatric death) with unvaccinated children.
To suggest, even "hypothetically" that no vaccination was necessary to travel outside the US is highly irresponsible. Parents who leave their children unvaccinated when taking them into the middle of an outbreak potentially make their children murder weapons – we posted the story of the pre-teen who spread measles in a waiting room as a consequence of which two children are now dying a very slow and horrific death.

Tetanus in an unvaccinated teen

The availability and wide us of vaccines and the resulting low incidence of the diseases which these vaccines prevent make a lot of parents perceive the disease as "low risk" in general. In late 2008, we could "watch" online how wrong this perception is, when a mother turned to an anti-vaccine board, whose son was developing lock jaw. Here is the link (for those of you who speak German or want to put the text through a translation site - my translations and summaries of the board posts are in blue):

The thread is entitled "Jaw problems after Tetanus vaccination".

Mein Sohn (13 Jahre) hat sich am Knie eine mind. 1,5 cm tiefe Wunde zugezogen. Da es auch noch schmutzig war, (Sand etc.) habe ich den Hausartzt erlaubt ihn gegen Tetanus zu impfen. Er war bis jetzt noch gar nicht geimpft gewesen. 2 Tage später klagte mein Sohn das er sein Mund kaum öffnen könne, essen wurde schwierig, auch Zähneputzen. Alles ist verspannt, Kiefer und Hals tun Weh, vor allem beim kauen.
Meine Frage ist jetzt, ob das eine Folge von Impfen sein kann, oder eine Zufall?
Wenn, ist es alarmierend oder geht`s vorbei automatisch?
Wäre heilfroh, wenn jemand Erfahrung hat mit sowas. Ich würde ungern zu den Arzt gehen, er ist Impffanatiker und ich kämpfe schon seit Jahren mit diese Thema.

In the first post the mom describes that her 13 year old, unvaccinated son sustained a knee injury (1.5 cm deep, dirty, sandy) and because he had not been vaccinated, she allowed his GP to "vaccinate him against tetanus". Two days later, the boy has problems opening his jaw, neck and jaw hurt when he tries to eat or brush teeth. She fears vaccine damage and wonders whether this will pass alone. She is also afraid to take her son to the doctor, because he is "vaccine fanatic".

At this point, I am thinking "OMG, this boy has tetanus - go see a doctor, but I am just watching, never got a password on this board, since reason is being heavily "moderated" by the board owner and his little helpers. However, the mum's post is immediately being picked up by the resident vaxxaloons - a poster by the name of Gaston remarks:

"This sounds just like Tetanus Symptoms" (wait if you think "well spotted, now he is going to send her to the doctor") - he continues "I would assume that your son would not have gotten these symptoms without the vaccine. After all, Tetanus Toxins are injected. So it is not surprising that here we are looking at something like beginning Tetanus."..

Mum responds "That is just what I thought. So I probably did the wrong thing again.
It is worse today. The boy can hardly eat. I will take him to the doctor at 6pm. I assume he will give a cortisone injection or something like that and tells me that he should have been vaccinated much earlier.
I really don't know what to do. This has been going on for 4 days and for the child it is very irritating. If at least I knew this is going to pass.
Well, at least I know for sure that none of my children will be vaccinated (this was the first time)."

A poster called "Anke" confirms the mother in her feelings and encourages her to report this as an adverse vaccine event. She also claims to have "heard of such symptoms associated with the tetanus vaccine".

A day later, she is taking her son to the doctor again. The doctor does not diagnose tetanus, but a throat infection and (because mom does not want him on antibiotics) she takes her son to the local pediatric hospital where he stays for observation. Doctors there think vaccine reaction AND tetanus are "unlikely".

In the thread, a poster called "Uschi" then shares her experience with jaw problems which she assumes were from her tetanus vaccination, which she later "chelated with the help of her homeopath".

"Gaston" pitches in with a terrible rant about the doctor. I feel like ranting about that doctor, after all, he did not diagnose the tetanus in a rather unambiguous presentation, but that is not what "Gaston" means. He is on a roll "if this was my child, I would do everything to hold this scumbag accountable. .../... The penicillin treatment, which is counter-indicated in this case, is the worst, because your son could have sustained further damage from it!"

Most further posters share these sentiments, however, "Sonnenlicht" asks whether the boy had received active or passive immunisation, because post-exposure, the boy would have needed immunoglobulins.

Four days have passed since the mum's first post.

Finally, the child is transferred to the next large University Hospital as the doctors clue in that he has tetanus. The boy can still talk, but cannot eat or drink. In that post, mom also says that her son had the active and passive immunisation a week earlier (that post is on page 2 of the thread). She assumes, her son's illness is from either of the the two.

Poster "Babsi" refers the mum to a vaccine-critical doctor in Bavaria. Poster "Kat" "knows" from her naturopathic pediatrician that the tetanus vaccine given "in case it has become serious, is particularly critical, i.e. badly tolerated." She is also adamant that if the wound had been bleeding "it is impossible that this was tetanus, it is vaccine damage!!!" (the three exclamation marks make it true, you know). Apart from that, she recommends a vaccine critical "expert" or "any naturopathic doctor for further help". "Gaston" totally shares her feelings. "The wound alone did not cause the problems, that was unambiguously the vaccine. It is generally known that vaccines cause the disease they are supposed to protect from in some. Some people are more susceptible for this." He suggests contacting the media "Tetanus after vaccination! Because Tetanus is really rare here in Europe." "Anke" pitches in and recommends Arnica globules in the 200C and consulting a homeopath. General rambling ensues.

A day later we get a chronological account. It appears that the wound was cleaned and sutured soon after the accident, but the immunisations were not given until the control visit 3 days later. The tetanus symptoms started another couple of days after that, so 5 or 6 days after the injury. Mum reports "Everyone in the University Hospital is convinced that he has tetanus from the wound, although it cannot be proven. I do believe it, too. The wound was very deep and got sutured = closed air tight. This disease is very rare. Even in the University Hospital no one had ever seen a single case. My son is better today. He was released from ICU and is on a normal ward now. He can still not open his mouth, but he could drink a little bit."

After this account, "Sonnenlicht" is also convinced that the tetanus was caused by the wound and that tetanus is an important vaccine after all. However, "presonic" would still not vaccinate in such a situation. S/he doesn't understand why "the dead flesh was not removed before the wound was sutured.". "Sonnenlicht" does not buy that. "Anke" just cannot believe that such a wound did not bleed profusely and the mother explains that her son had a bicycle accident on an asphalted path and a deep wound next to the knee that did bleed. She is unsure whether the doctor cleaned the would appropriately.

Two weeks later, we get the resolution that the boy is home again, after nearly two weeks in the hospital on antibiotics, tetanus immunoglobulins and "lots of other medicines". The mother describes that her son had "not fared as poorly as she was told to expect" - he could breathe on his own and did not get "bad" cramps. He could not open his mouth and his tongue hurt. He started to make an effort to eat when the doctors discussed giving him a stomach probe to feed him.

This story is shocking on several levels. Obviously, I pity the child. An injured knee should not put a 13 year old in the hospital with tetanus. He was obviously very uncomfortable the whole time and mum sounds very desperate, too. The doctors' reactions in hindsight (which is always 20/20 ;)) were not stellar, the reaction of the resident anti-vaccine posters on that board are so out-worldly that they look almost staged. They may even have contributed to the delay until the boy was taken to the hospital.

Tetanus in children is very rare - so rare in fact, that doctors do no longer necessarily clue in when they are faced with a child with a locked jaw. However, 80% of the few pediatric cases of tetanus occur in unvaccinated children. They don't need dramatic injuries, blunt trauma, or minor splinters can be enough of a cause. Tetanus in children is very rare, however, we need to remember that most toddlers (over 96% according to the latest US figures, European figures are similar) have had at least 3 vaccines against tetanus - protection up to the school booster is near perfect, see also here, and most kids in the US will get that first school booster that protects them into adolescence, when 75% of US kids are getting another booster.

So the bottom line is: parents who do not vaccinate against tetanus need to be aware that the low incidence of tetanus is in part due to the high vaccination coverage. They themselves need to keep tetanus in mind when their unvaccinated children have an accident, since doctors might not automatically assume that s/he is looking at one of the 4/100 children who does not have tetanus protection and will almost certainly not have experience with tetanus. If worrying about tetanus with every splinter is too stressful for the parents, the alternative is NOT to post on an anti-vaccine board for encouragement that "head in the sand" is the best option, because 1. vaccines are teh ebil and 2. they are particularly evil after exposure.

The reasonable alternative is to consider vaccination.

20 Aug 2014: links repaired